READY, FIRE, AIM: DOES INTEGRATING ACUTE AND LONG-TERM SERVICES WORK?

Abstract Due to the increasing costs of Medicaid and Medicare and concerns about how these two programs fail to work together to deliver quality care, there has been a growing enthusiasm for integrated care programs. The Financial Alignment Initiatives (FAI), implemented by the Centers for Medicare and Medicaid Services (CMS) in 2011 and tested in 13 states were designed to test the impacts of a program that offers Medicare and Medicaid services under one organization to individuals who are dually eligible for both programs. Previous studies of the expansion of managed long-term services have generated considerable interest over the last two decades however, research results have been mixed. There is also limited information about the implementation of these efforts, as demonstrations have served varying target populations with very different intervention strategies. The lack of conclusive results means that states, now faced with decisions about continued implementation of these initiatives do not have good information to make sound policy decisions. The national evaluation of the FAI states did not include Medicaid costs. Our study is designed to gain a better understanding of Ohio’s FAI MyCare Demonstration. This symposium provides data from a comprehensive impact analysis that examined both Medicaid and Medicare claims data using a difference- in- differences treatment and comparison analysis (n= 390,000) and an in-depth process evaluation (using interviews with 487 participants) to gain an understanding of program effects. After reviewing results the symposium will discuss the future of these and other reform efforts to integrate Medicaid and Medicare services.


THE LONG-TERM CARE STAFFING CRISIS AND COVID-19: ROLE OF THE NURSE PRACTITIONER Katherine McGilton, KITE Research Institute: Toronto Rehabilitation Institute-UHN, Toronto, Ontario, Canada
The residential long-term care sector has historically suffered from seemingly intractable staffing challenges in terms of ensuring adequate clinical expertise and a supportive work environment to address the complex health care needs of residents. Considerable evidence has demonstrated the devastating effect of COVID-19 on this fragile residential long-term care staffing structure, resulting in adverse outcomes among staff and residents alike, with the potential for permanent devastation without directed intervention. Drawing upon data from an Ontario-based study of nurse practitioner deployment during COVID-19, this talk will share an emergent approach to re-shaping expertise and capacity in Ontario, Canada through embedding nurse practitioners in residential long-term care homes. Results of this work helped to inform health policy action in the province to scale-up the use of nurse practitioners in long-term care homes, in order to enhance staff expertise and tackle the significant inequities of access to care among nursing home residents.

A LOOK INSIDE THE MISSOURI NURSING HOME COVID-19 EXPERIENCE Amy Vogelsmeier, and Lori Popejoy, University of Missouri, Columbia, Missouri, United States
The COVID-19 pandemic exposed the vulnerabilities of US nursing homes to manage widespread viral outbreaks including an ill prepared/under-resourced workforce, a physical environment not conducive to infection prevention or management, and isolation from community emergency response planning. In this session, we will share real-life, real-time experiences of diverse Missouri nursing homes as they responded to the COVID-19 pandemic. We will also report on emerging data about the impact of nursing homes' pandemic response on resident outcomes. Strategies such as community-based efforts to respond to resource scarcity, and creative workforce solutions to address staffing needs, will be shared. Critical next steps should focus on the implementation of community coalitions to create sustainable healthcare partnerships at the local and state level and enhanced workforce solutions that include registered nurses and advanced practice registered nurses working within nursing homes to guide clinical care and infection prevention and management strategies.

READY, FIRE, AIM: DOES INTEGRATING ACUTE AND LONG-TERM SERVICES WORK? Chair: Robert Applebaum Discussant: Richard Browdie
Due to the increasing costs of Medicaid and Medicare and concerns about how these two programs fail to work together to deliver quality care, there has been a growing enthusiasm for integrated care programs. The Financial Alignment Initiatives (FAI), implemented by the Centers for Medicare and Medicaid Services (CMS) in 2011 and tested in 13 states were designed to test the impacts of a program that offers Medicare and Medicaid services under one organization to individuals who are dually eligible for both programs. Previous studies of the expansion of managed long-term services have generated considerable interest over the last two decades however, research results have been mixed. There is also limited information about the implementation of these efforts, as demonstrations have served varying target populations with very different intervention strategies. The lack of conclusive results means that states, now faced with decisions about continued implementation of these initiatives do not have good information to make sound policy decisions. The national evaluation of the FAI states did not include Medicaid costs. Our study is designed to gain a better understanding of Ohio's FAI MyCare Demonstration. This symposium provides data from a comprehensive impact analysis that examined both Medicaid and Medicare claims data using a difference-in-differences treatment and comparison analysis (n= 390,000) and an in-depth process evaluation (using interviews with 487 participants) to gain an understanding of program effects. After reviewing results the symposium will discuss the future of these and other reform efforts to integrate Medicaid and Medicare services.

WHEN YOU GET TO A FORK IN THE ROAD, TAKE IT: SHOULD STATES FOLLOW YOGI'S ADVICE ON MANAGED LONG-TERM SERVICES? Robert Applebaum, Miami University, Oxford, Ohio, United States
Today's Medicaid challenges, coupled with the baby boom demographics, have every state in the nation recognizing the need to do something different in their Medicaid programs. Although achieving a better balance between institutional and home and community-based services has been an important reform in many states, it does not appear to be enough to create a working system. Medicaid managed long-term care and efforts to integrate Medicare and Medicaid is a growing option. Designed to control the acute and long-term care costs of older people and individuals with disability, the approach also is directed at linking the two disparate systems. A review of the array of studies examining this area shows mixed results, despite the popularity of this option at the state level. This paper introduces the evaluation of Ohio's MyCare integrated care demonstration, raising questions about the important elements of these initiatives for policy makers, providers, and consumers. John Bowblis, Robert Applebaum, and Matt Nelson, Miami University, Oxford, Ohio, United States In 2014, 29 of 88 Ohio counties implemented MyCare, which integrated Medicare and Medicaid for dually eligible Ohioans. Using an intent-to-treat, difference-in-difference framework we examined medical expenditures and utilization associated with the implementation of MyCare. Specifically, we compared dually eligible Ohioans in MyCare counties to those in non-MyCare counties from 2012 to 2018. Overall medical expenditures were lower in the MyCare counties post implementation compared to non-Mycare counties, with most of the difference attributed to Medicaid. The effects were larger for individuals in the community compared to long-term services and supports (LTSS) users. The implementation of MyCare is associated with a decrease in the use of nursing homes, a large increase in hospice, and among LTSS users not in a nursing home decreases in the utilization of home and community-based services. Interestingly, the proportion of individuals in MyCare counties classified as an LTSS user increased after the implementation of MyCare.

PROGRAM THEORY VERSUS IMPLEMENTATION: THE IMPORTANCE OF PROCESS IN UNDERSTANDING PROGRAM IMPACT
Jennifer Heston-Mullins 1 , Athena Koumoutzis 2 , Katherine Abbott 2 , Dayna Bennett 2 , and Karen Williams 2 , 1. Scripps Gerontology Center,Miami University,Oxford,Ohio,United States,2. Miami University,Oxford,Ohio,United States An extensive MyCare Ohio process evaluation was conducted to understand factors affecting everyday implementation. This involved a review of MyCare membership enrollment data and qualitative interviews and focus groups with state-level stakeholders (n=29), regional stakeholders comprised of Area Agency on Aging and MyCare Ohio Plan personnel and HCBS service providers (n=418), and MyCare members (n=40); which were audio-recorded, transcribed, and checked for accuracy prior to coding in Dedoose. Results show that while MyCare was originally envisioned as a program to coordinate Medicare and Medicaid services for dual-eligible, physically-disabled older adults, many MyCare members are under age 65 (47%), have opted out of the Medicare Advantage portion of MyCare (42%), and live with behavioral health diagnoses. This presentation will discuss how process evaluation is instrumental to understanding program impact and how younger members, members with behavioral health concerns, and opted-out members have shaped the implementation of MyCare Ohio. Within Ohio's MyCare demonstration, two distinct care management models were selected by the participating MyCare Ohio health plans (MCOPs): fully-delegated waiver care management and waiver service coordination. The purpose of this presentation is to describe the components of care management operating in MyCare Ohio. Qualitative interviews with n=91 Area Agency on Aging (AAA) and n=131 MCOP care management personnel were audio-recorded, transcribed, and checked for accuracy prior to thematic coding in Dedoose. Results indicate that comprehensive care management is the core element of MyCare Ohio. Fully-delegated care management models were viewed by participants as beneficial to reducing confusion for members however 'scope creep' challenged the already strained AAAs. Effective teamwork was identified for waiver service coordination models